An Unexpected Turn During Staff Relief

By: Haley Flambaum

Staff relief is a challenging time for interns. It’s a chance for them to solidify their knowledge, work independently and reinforce much of what they learned during their main clinical rotation. During their clinical staff relief, most interns are assigned a floor in their hospital and they are responsible for those patients. The preceptor expects them to see between eight to ten patients per day and update their charts. 

That was not the case for my staff relief.

My first week of staff relief started as normal. I was assigned to Floor 7 of my hospital and I was expected to see and chart those patients each day. Floor 7 did not have any specific types of patients, so I was exposed to a wide variety of medical conditions. I woke up on Tuesday morning of my second week of staff relief with a text from my preceptor saying, “Morning… looks like the COVID bug got me finally. I tested positive this morning and so did our Clinical Nutrition Manager (CNM). So when you get in just screen everyone except those in the Intensive Care Unit. Take as many as you can.” My brain was spiraling at this point thinking about how I was going to be the only inpatient “dietitian” there.  Per protocol, one of my preceptors still had to review my notes and co-sign them. This task was given to our outpatient oncology dietitian. My preceptor and CNM texted me saying that they trusted my clinical judgment. 

At first, I wanted to freak out. I took a much-needed deep breath and thought, “This is an opportunity that not many people get.” I decided that I would take this experience and use it as a way to improve my clinical nutrition skills. If my CNM and preceptor had trust in me, then I had to have trust in myself. I knew that I had the knowledge, gained from my undergrad and the previous 7 weeks of the internship, to guide me to a successful experience. 

I started each day by checking our consult list and then moving to screen regular floors to find follow-ups. My goal was to see every consult and follow-up each day. I screened 13 patients on the first day of solo staff relief. Prior to that, my maximum number for seeing and charting patients was 10. I knew I had it in myself to be effective and manage my time in order to see every patient that needed to be seen. After screening, I would make a sticky note of the categories of patients I needed to see. 

The categories were: 

  • Total Parental Nutrition (TPN)/Enteral Nutrition (EN): TPN is a method of feeding that is given through a vein. EN, also known as tube feeding, is a way of giving nutrition directly into the gastrointestinal tract. 
  • Follow-ups: Depending on the severity of a patient, that individual will need to be seen for a follow-up. A follow-up occurs after the initial consultation with the patient. If a patient is in a more severe nutrition state, per St. Joe’s Medical Center protocol, a dietitian will see the patient three days after the initial consultation. If a patient is in a mild nutrition state, a dietitian could see the patient a week to ten days after the initial consultation. A follow-up is meant to summarize events that have happened since the last time the patient was seen and to update their nutrition interventions.
  • Diet Education: Most diet educations I completed were about following a heart-healthy diet or a consistent carbohydrate diet. For each diet education, I would print a handout for the patient, go over the material with them, and answer any questions the patient had.   
  • Malnutrition Screening: Another healthcare discipline will fill out a form based on a patient’s nutritional status. The form covers weight loss, inadequate oral intake, open wounds, and more. The disciplinarian will score these categories. If the patient scores a two or higher, the nutrition department is consulted to talk to the patient.  
  • Nothing by Mouth (NPO): A dietitian will go talk to a patient if they have been NPO x five days (three if it is on a Friday).
  • Other: Other disciplines will consult nutrition services to talk to a patient and assess their nutrition status. For example, a doctor could consult a dietitian to conduct a calorie count if the patient is not eating properly. 

The diet educations were sprinkled all throughout the day. It is important that the patient receives nutrition education before they are discharged to ensure proper recovery at home. I started with TPN/EN because I knew those would take me the longest. I gained confidence in my TPN/EN calculation skills throughout this clinical rotation, so I was excited to be exposed to more opportunities to provide recommendations. I would bring my formulary card when I saw each patient. The formulary card contained all the information regarding my hospital’s enteral nutrition supplements and oral nutrition supplements. I knew this would be a valuable tool if a patient ever had a question about supplements. The formulary card also helped me decide which enteral nutrition formulas would work best for my patients that needed them. 

On average, I would see 10 patients per day. I wouldn’t have had the confidence to handle the situation on my own if I didn’t learn so much during my clinical rotation and gain the trust of my preceptors throughout the rotation. With the help of what I learned in my undergrad and what I have been learning through this internship at UMD, I was able to use that knowledge to help me succeed. By the end of the first week, I was seeing patients on my own and advancing my charting skills. With each completed note, came more confidence in myself and more trust from my preceptors. I was incrementally building my clinical judgment.  This experience taught me so much, especially how to have trust in myself and my nutrition skills. I learned what it would be like to be a clinical dietitian. I learned how to adapt to different situations depending on the patient. I also learned that it is okay to not know everything. This experience taught me the benefits of being flexible and adaptable in the world of dietetics … you never know what is coming your way.

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